HANDLING A TRAUMA PATIENT

Injury to the human body occurs when it is exposed to sudden transfer of high energy that the body can’t withstand.

TRIMODAL PEAK OF DEATH:

1st Peak ( Immediate ) 50%

• Within first few minutes of injury
• Extensive trauma to Brain, Upper Spinal Cord, Heart or Major Blood Vessels, Rupture of Major Airway.
• Little can be done to salvage the Patient.

2nd Peak ( Early Deaths ) 30%

• Within first few hours of Injury
• Subdural/Epidural Hematoma
• Hemo/Pnemothorax
• Organ Rupture/Blood Loss
• Pelvic/long Bone Fracture

3rd Peak ( Late Deaths) 20%

• Weeks after Injury
• Multiorgan failure
• Sepsis

MANAGEMENT OF POLY-TRAUMATIZED PATIENT

There are many protocols for management of poly-trauma, the most universally accepted one is the protocol of ATLS (ADVANCED TRAUMA LIFE SUPPORT) which described by the American College of Surgeons, which consists of 3 steps:

• Primary survey.
• Secondary survey.
• Definitive treatment.

Another protocol is the 5 Rs, as follows

• R1: Rapid Evaluation = Triage.
• R2: Resuscitation.
• R3: Radiology and Other Investigations.
• R4: Re-Evaluation.
• R5: Repair and Rehabilitation.

 R1: RAPID EVALUATION = TRIAGE

Within few seconds you have to be able to put your patients in one of the following categories;

• Black (White) Zone: for those who are dead or dying(e.g. brain herniation).

• Red Zone: for those who needs urgent interference within 5-10 minutes (e.g. those with external hemorrhage and respiratory compromise).

• Yellow Zone: for those who needs also urgent intervention but could withstand for 1-2 hours with in which some resuscitation and investigations could be done (e.g. Internal hemorrhage patients).

• Green Zone: for those who needs intervention within 1-2 days (e.g. patients with fractures).

R2: RESUSCITATION

Including the urgent measures that should be done for the patient immediately after the accident (in the field of the accident) to save his life during the first minutes or hours(the golden hours), they should be done in the order of priority A B C D E as follows:

A-Airway:

B-Breathing:

C-Circulation:

D-Disability (Neurological Assessment):

E-Exposure:

A-AIRWAY:

• The patient’s airway should be evaluated and protected. In general, if the patient is capable of unstrained speech, his airway is patent. All patients should receive supplemental oxygen by mask till they reach the hospital.

Asses for: obstruction, facial fractures, tracheal injuries, tracheal deviation.

• Apply hard cervical collar.
• Open airway by doing jaw thrust maneuver (chin lift).
• Open the mouth, remove the obstruction or secretion. Do suction to remove any obstruction (e.g. secretions, blood, vomitus or any foreign body).

Insert oro-pharyngeal or naso-pharyngeal airway to maintain patency of airway and to prevent falling back of the tongue in an unconscious patient. This method is contra-indicated in conscious patients (stimulates gag reflex and vomiting)

Endo-tracheal Intubation (indicated in cases of apnea, head injuries, air way compromise like maxillofacial injuries, fracture cervical spine and if there is risk of aspiration).

Cricothyroidotomy : If there is upper airway obstruction and it is impossible to pass an endo-tracheal tube.

B-BREATHING:

Check for spontaneous breathing for 10 sec;

• If patient is breathing satisfactorily & PO2 above 90%» justobserve.
• If patient is breathing satisfactorily but PO2 below 90% »provide o2 therapy via mask 6 L/min, 60% O2 concentration.
• If patient is not breathing or PO2 still declining » manually ventilate patient with 15L/min, 100% oxygen concentration &Prepare for intubation and mechanical ventilation.

C-CIRCULATION:

Check peripheral pulsations: tachy- or brady- cardia.

Check Blood Pressure: be rapid and accurate in its measurement.

Check neck veins: is it

• Collapsed—– Hypovolemia.
• Distended—- Impaired Venous Return.
• Tension Pneumothorax; treat it immediately.
• Cardiac Tamponade; treat it immediately by Pericardiocentesis
• Myocardial Contusion & Infarction.

Fluids:

• 2 large bore IV Cannulas&starting with bolus IV fluids-10ml/kg(crystalloid)usual choice RL&NS
• If patient is stable maintenance fluids according to  patients weight will be continued &monitored with the help of blood pressure& urine output
• If immediate blood is not available patient can be started on crystalliods(HEMECEAL)after taking sample for blood group testing.
• O-ve can be transfused without waiting for grouping if available.

If the patient is in shock (neurogenic, oligaemic or cardiogenic), start

immediately anti-shock measures (arrest of bleeding, infusion of lactated

Ringer’s sol., and blood transfusion once available).

D-DISABILITY (Neurological Assessment):

Level of consciousness.

• AVPU scale;

• Awake.
• Verbal response.
• Pain response.
• Unresponsive.

For assessment, apply any scale e.g Glasgow Coma Scale.

GLASGOW COMA SCALE

• 3 – 15 point scale to assess mental status only
• Best observed response
• GCS ≤ 8 is a “coma” and requires intubation for airway protection

EYE OPENING	VERBAL RESPONSE	MOTOR RESPONSE
None-1	None-1	None-1
To painful stimuli only = 2	Incomprehensible sounds-2	Decerebrate posturing-2
To voice only-3	Incomprehensible words-3	Decorticate posturing-3
Spontaneously open-4	Confused-4	Withdraws to pain-4
	Oriented-5	Localizes pain-5
		Follows commands-6

E-EXPOSURE:

• Remove clothing.
• Observe the chest for bruises, penetrations, and symmetry.
• Auscultate breath sounds.
• Auscultate heart sounds.
• For total assessment.

After exposure you may find:

Ecchymosis at site of trauma.

R3: RADIOLOGY & OTHER INVESTIGATIONS.

I- Basic X-Ray Films have to be done for every case of Polytrauma depends largely on the suspected site and the doctor who is going to request it. Every specialty has its own interest;

General Surgery: erect abdomen

Cardiothoracic Surgery: chest x-ray

Neurosurgery: skull and spines

Orthopedic Surgery: pelvis, spine and fractures

R4: RE-EVALUATION

(Secondary survey)

Now, this is the time of re-evaluation of the patient. It is done in two steps:

-History taking: this includes; SAMPLE;

• Symptoms.
• Allergies.
• Medications.
• Past history.
• q2Last meal.
• Events related to injury.

II-General Examination from Hair to Heal:

1.Head: search for sub-galeal hematoma, sub-conjunctival hemorrhage, facial fractures,…etc.

2.Neck: pain or tenderness, tracheal deviation, jugular vein, impaled objects and open wounds, Expanding neck hematoma.

3.Heart: rib fractures, pneumo- or hemo-thorax,…etc.

4. Abdomen & Pelvis: Cullen’s sign, Grey-Turner sign,Kher’s sign,…etc.

5.Extremities: Fractures, peripheral pulsations, soft tissue injuries,…etc.

6.Back: bruising, impaled objects, pain and tenderness.

Chest:

   Inspect the chest, observe the chest movements. Look in

particular for:  

• bruising (from seat-belts)
• asymmetric or paradoxical chest wall movement
• penetrating wounds are rare in children, but in cases

where there is a stabbing or other assault look for

“hidden” wounds – checking areas such as the axilla and

back

Palpate for clavicular and rib tenderness and auscultate the

lung fields and heart sounds.

Abdomen:

Inspect the abdomen, the perineum and external genitalia. Look

for in particular for:

   seat-belt bruising / handle-bar injuries

• distension

• blood at the urinary meatus / introitus

Palpate for areas of tenderness especially over the liver, spleen,kidneys and bladder, and auscultate bowel sounds.

Pelvis:

Inspect the pelvis for grazes over the iliac crest. Examine for bruising, deformity, pain or crepitus on movement.

R5: REPAIR & REHABILITATION.

(Definitive treatment of individual injuries )

Finally, the patient is admitted to the hospital in one of the following destination sites:

• General Surgery Department.
• Neurosurgery Department.
• Orthopedic Surgery Department.
• Cardiothoracic Surgery Department.
• ICU.